FURIOUS! Ambulance Refused to Transport Patient

The joys of living in a small town........had a patient who was found on the floor of his apartment, barely responding, unable to stand or sit up, unable to answer what day it was, eyes rolling back in head, apnea, in and out of consciousness. The patient lives alone with no family or caregivers available to stay in the home with him. Patient is end stage cirrhosis of liver. Phoned ambulance service for non-emergent transport to hospital. Paramedic comes in (happens to own the ambulance service, as well) and asks patient if he wants to go to the hospital. Patient can barely arouse but says 'no'. Paramedic says "call off the run, we can't take a patient if they say no." WHAT THE......??????? I got a little ticked (understatement) and said "He's barely conscious, he has fallen, he cannot adequately answer questions, and you think he's coherent enough to make that decision on his own????" Paramedic got a little ticked (understatement) and began to lecture about how it's false imprisonment to force a patient to go to the hospital, and I really need to calm down here......That's when I REALLY lost it (not proud of that, but it happened) and said "I wouldn't have called you if I hadn't needed you. He is not capable of making a sound decision at this point in time. We need to get him to a safe place." Paramedic then tells me "It's MY ambulance (it is, really) and I get to say who gets to ride in it. You can't tell me what to do." I looked at him and said "Well, walk out and I WILL report you for abandoning the patient." Then it got a whole lot uglier from there verbally.

Eventually I called in another nurse because I knew I had lost control of the situation and was not coherent myself . She smoothed it out and patient was transported. Turns out he had overdosed on medications. I found out later there is a law in my state that says if a patient is incoherent, they are incapacitated and MUST be transported to a higher lever of care. I AM FURIOUS. Was I wrong? And should I just let this go or complain officially? Any advice appreciated.

The joys of living in a small town........had a patient who was found on the floor of his apartment, barely responding, unable to stand or sit up, unable to answer what day it was, eyes rolling back in head, apnea, in and out of consciousness. The patient lives alone with no family or caregivers available to stay in the home with him. Patient is end stage cirrhosis of liver. Phoned ambulance service for non-emergent transport to hospital. Paramedic comes in (happens to own the ambulance service, as well) and asks patient if he wants to go to the hospital. Patient can barely arouse but says 'no'. Paramedic says "call off the run, we can't take a patient if they say no." WHAT THE......??????? I got a little ticked (understatement) and said "He's barely conscious, he has fallen, he cannot adequately answer questions, and you think he's coherent enough to make that decision on his own????" Paramedic got a little ticked (understatement) and began to lecture about how it's false imprisonment to force a patient to go to the hospital, and I really need to calm down here......That's when I REALLY lost it (not proud of that, but it happened) and said "I wouldn't have called you if I hadn't needed you. He is not capable of making a sound decision at this point in time. We need to get him to a safe place." Paramedic then tells me "It's MY ambulance (it is, really) and I get to say who gets to ride in it. You can't tell me what to do." I looked at him and said "Well, walk out and I WILL report you for abandoning the patient." Then it got a whole lot uglier from there verbally.

Eventually I called in another nurse because I knew I had lost control of the situation and was not coherent myself . She smoothed it out and patient was transported. Turns out he had overdosed on medications. I found out later there is a law in my state that says if a patient is incoherent, they are incapacitated and MUST be transported to a higher lever of care. I AM FURIOUS. Was I wrong? And should I just let this go or complain officially? Any advice appreciated.

I would report it officially b/c sometimes parametics have just enough knowledge to be very dangerous.

If the man is in and out of consciousness and can possibly have a head injury, then it's safe to say that he cannot give informed consent.

If that were the case, then every patient who is in the ER who said, "No, stop, that hurts!", would just be left to their own devices.

To me, parametics and ambulance services are not exempt from that.

It was a very poor judgement call and there would be no question in my mind of filing a formal complaint.

Dec 7, '08

You said you phoned for a non-emergent transfer. If the paramedic's ambulance didn't have MICU capabilities it's no wonder he refused. Emergent transfer via whomever contracts with 911 for the area was needed, in my opinion (EMT here), as there was a clear potential for advanced airway management and/or resu equipment (not to mention narcan).

Still, the paramedic should not have left but should have stayed on scene until EMS arrived.

Dec 7, '08

I agree, there needs to be an incident report filed.

Dec 7, '08

You need to write a letter to the state board, whoever governs paramedics in your state. Also, make a copy of it and send it certified, return reciept.
This should be officially reported so that it won't happen again from the same paramedic. It seems like he is even much more dangerous since he owns his ambulance.

Dec 7, '08

I can see both sides of the issue, the patient was conscious enough at the time to say no. When someone refuses to be transported there is nothing the ambulance can do. You, not being POA would actually have no say in the matter legally. You can use your judgement and experience however to let them know as a nursing student (which your page states you are), it is your judgement that the patient is too incoherent to make that decision and they in turn should have stayed a little longer to assess it themselves.

I had someone very close to me refuse the ambulance twice and if she would have been actually brought to the hospital, I doubt she would have sued, but would have refused all treatment also. The only way her family got her there was when she was unconscious.... by then she was so ill she wound up in ICU. I personally wish there was better options legally and morally and would be interested in hearing what others have to say.

I personally wish there was better options legally and morally and would be interested in hearing what others have to say.

People have the right, that is to say, the autonomy, to make stupid decisions. This is unfortunate job security for all of us in health care. I think the ethical track is to educate the patient as best as we can and if they still decide to make the stupid decision (refusing emergent treatment), provided they are of sound mind at the time, we just have to shake our heads and let them go. And return to scene two hours later when their mind isn't so sound, as is often the case.

Dec 7, '08

An incident report will sort all this. The whole point of reporting it is to have it investigated and examine what the policy is, ethical considerations, and all that.

I can see both sides of the issue, the patient was conscious enough at the time to say no. When someone refuses to be transported there is nothing the ambulance can do. You, not being POA would actually have no say in the matter legally. You can use your judgement and experience however to let them know as a nursing student (which your page states you are), it is your judgement that the patient is too incoherent to make that decision and they in turn should have stayed a little longer to assess it themselves.

I had someone very close to me refuse the ambulance twice and if she would have been actually brought to the hospital, I doubt she would have sued, but would have refused all treatment also. The only way her family got her there was when she was unconscious.... by then she was so ill she wound up in ICU. I personally wish there was better options legally and morally and would be interested in hearing what others have to say.

the paramedic knew exactly what to ask, to keep this person out of his ambulance....probably concerned about a potential clean up.
and he was stretching the point on "i say who rides in my ambulance" if he is contracted to provide a service, he needs to provide it..

Dec 7, '08

I don't know what state you are in, but in my state, all EMS agencies (including critical care transports) are required to get medical advice (usually from the ER docs where the patient would be transported) on the acceptance of a refusal of transport. If this paramedic made the decision without contact for physician approval, he could lose his certification in the state I live in.

Just as a post script, it is not uncommon to encounter this kind of cowboy attitude in the rural setting. I work professionally as a transport RN, but also volunteer on a rural ambulance in the community that I live in. One of the most aggravating things I face is the cowboy attitude of a few of the volunteer EMT's. Some become EMT's for the t-shirt and the privilege of strutting around the community with their inflated ego's. On the other hand, we also have some very dedicated volunteers that take their job seriously and have excellent skills. Sadly, it only takes a few cowboy's to ruin the reputation of the good EMT's. Hopefully, this one paramedic in your situation hasn't ruined the other's on his service.

Dec 7, '08

Reminds me of the discussion I heard about the RT at work who claimed its abuse and assault to force a patient to wear their bipap mask (in ICU), the patient clearly confused, retaining cO2, who NEEDs the bipap, and is getting MORE confused because they keep taking it off. so then what, if the patient is intubated and keeps extubating themselves, we cant force them to allow us to reintubate? Despite them clearly being confused and having poor judgement? Clearly we restrain many patients who are intubated because they are confused, so I dont see the difference with the patient needing bipap. I also agree with you that the Ambulance driver was WAY out of line. Just because someone says no, doesnt mean they can refuse. Thats my opinion. I just dont see how it could ever be right to allow someone who is confused, non-coherent to make decisions about themselves.

People have the right, that is to say, the autonomy, to make stupid decisions. This is unfortunate job security for all of us in health care. I think the ethical track is to educate the patient as best as we can and if they still decide to make the stupid decision (refusing emergent treatment), provided they are of sound mind at the time, we just have to shake our heads and let them go. And return to scene two hours later when their mind isn't so sound, as is often the case.

Theres a difference between a "stupid decision" that is based out of pure stupidity and ignorance, and a patient having a medical issue, clouding better judgement.

If the patient is not of sound mind, they cant refuse treatment. If they refused, and we as healthcare providers said, fine, we wont do anything for you, and miraculously they get better, and come to realize they had poor judgment, but couldnt help it due to the medical issue and were harmed maybe in some way along the process because we didnt do everything in our power to help them when they werent of sound mind, dont you think our rear ends would be sued?? Im sure we would not be able to argue the fact that the confused patient "refused".

I don't know what state you are in, but in my state, all EMS agencies (including critical care transports) are required to get medical advice (usually from the ER docs where the patient would be transported) on the acceptance of a refusal of transport. If this paramedic made the decision without contact for physician approval, he could lose his certification in the state I live in.

It's not this way in Texas. We just chart the refusal, sometimes without even getting ID-- back when I was active EMS we'd show up at MVCs where everyone was superficially fine and everyone rejected EMS treatment and transfer on a daily basis.